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Copyright © The McGraw-Hill Companies, Inc. All rights reserved.www.harrisonspractice.com
Abdominal Pain
(See also
Harrison’s Principles of Internal Medicine
, 17
th
Edition, Chapter 14)
Definitionn
•
Pain in the abdomen ranging from acute, life-threatening emergencies to chronicfunctional disease and disorders of several organ systems
•
Evaluation of acute pain requires rapid assessment of likely causes and earlyinitiation of appropriate therapy.
•
A more detailed and time-consuming approach to diagnosis may be followed inless-acute situations.
•
Incidence
o
One of the most common presenting problems in emergency medicine
o
Accounts for ~10% of all emergency department visits
o
Half of healthy adults have abdominal pain on questioning.
•
Age and sex
o
Dependent on cause of abdominal pain
•
Pain originating in the abdomen
o
Inflammation of the parietal peritoneum
o
Obstruction of hollow viscus
o
Vascular disturbances
o
Abdominal wall
o
Distension of visceral surfaces
•
Pain referred from extra-abdominal sources
•
Metabolic causes
•
Neurogenic causes
•
Functional causes
•
Inflammation of parietal peritoneum: pain characteristics
o
Quality: steady and aching
o
Location: directly over inflamed area with exact reference possible
o
Intensity: dependent on type and amount of material to which peritonealsurfaces are exposed in a given time period
Sudden release into peritoneal cavity of small quantity of sterile acidgastric juice causes much more pain than same amount of grosslycontaminated neutral feces.
Copyright © The McGraw-Hill Companies, Inc. All rights reserved.www.harrisonspractice.com
Enzymatically active pancreatic juice causes more pain andinflammation than same amount of sterile bile containing no potentenzymes.
Blood and urine are often so bland they are detected only if contactwith peritoneum is sudden or massive.
In bacterial contamination (e.g., pelvic inflammatory disease), pain isfrequently of low intensity until bacterial multiplication has causedelaboration of irritating substances.
o
Rate at which irritating material is applied to peritoneum is important.
Perforated peptic ulcer: clinical picture dependent only on rapidity withwhich gastric juice enters peritoneal cavity
o
Pain is accentuated by pressure or changes in tension of peritoneum.
Produced by palpation or movement (e.g., coughing, sneezing)
Patient with peritonitis lies quietly in bed to avoid painful motion.
Patient with colic may writhe incessantly.
o
Tonic reflex spasm of abdominal musculature
Localized to involved body segment
Intensity of spasm is dependent on location and rate of developmentof inflammatory process and integrity of nervous system.
Spasm over perforated retrocecal appendix or perforated ulcer intolesser peritoneal sac may be minimal or absent because of protectiveeffect of overlying viscera.
Slowly developing process often greatly attenuates degree of spasm.
o
Possibly minimal or no detectable pain or spasm in obtunded, seriously ill,debilitated elderly, or psychotic patients; even in catastrophic abdominalemergencies (e.g., perforated ulcer).
•
Obstruction of hollow viscera: pain characteristics
o
Classically described as intermittent or colicky
Produces steady pain with occasional exacerbations
Not nearly as well localized as pain of parietal peritoneal inflammation
o
Obstruction of small intestine
Colicky pain
Usually periumbilical or supraumbilical
Poorly localized
As intestine becomes progressively dilated with loss of muscular tone,colicky nature may diminish.
With superimposed strangulating obstruction, pain may spread tolower lumbar region if there is traction on root of mesentery.
o
Colonic obstruction
Colicky pain of lesser intensity than that of small intestine
Often located in infraumbilical area
Lumbar radiation common
o
Acute distention of gallbladder
Steady rather than colicky pain; term
biliary colic
misleading
Usually pain in right upper quadrant with radiation to right posteriorregion of thorax or to tip of right scapula
o
Acute distention of common bile duct
Often pain in epigastrium radiating to upper part of lumbar region
Considerable variation is common; differentiation between this andacute distention of gallbladder may be impossible; typical subscapularpain or lumbar radiation is frequently absent.
o
Gradual dilatation of biliary tree (e.g., carcinoma of head of pancreas)
May cause no pain or only mild aching sensation in epigastrium orright upper quadrant
o
Distention of pancreatic ducts
Pain similar to distention of common bile duct
2Abdominal Pain
Copyright © The McGraw-Hill Companies, Inc. All rights reserved.www.harrisonspractice.com
Very frequently accentuated by recumbency and relieved by uprightposition
o
Obstruction of urinary bladder
Dull suprapubic pain, usually low in intensity
Restlessness without specific complaint of pain may be only sign of distended bladder in obtunded patient.
o
Acute obstruction of intravesicular portion of ureter
Severe suprapubic and flank pain that radiates to penis, scrotum, orinner aspect of upper thigh
o
Obstruction of ureteropelvic junction
Pain in costovertebral angle
o
Obstruction of remainder of ureter
Flank pain that often extends into same side of abdomen
•
Vascular disturbances
o
Pain not always sudden or catastrophic
o
Embolism or thrombosis of superior mesenteric artery or impending ruptureof abdominal aortic aneurysm
Pain may be severe and diffuse.
o
Occlusion of superior mesenteric artery
Pain may be mild, continuous, and diffuse for 2 or 3 days beforevascular collapse or findings of peritoneal inflammation appear or maybe severe and diffuse.
Early, insignificant discomfort is caused by hyperperistalsis rather thanperitoneal inflammation.
Absence of tenderness and rigidity in presence of continuous, diffusepain are characteristic of vascular disease.
o
Rupturing abdominal aortic aneurysm
Abdominal pain with radiation to sacral region, flank, or genitalia
Pain may persist over several days before rupture and collapse occur.
•
Abdominal wall
o
Usually constant and aching
o
Movement, prolonged standing, and pressure accentuate discomfort andmuscle spasm.
o
Hematoma of rectus sheath
Most frequently with anticoagulant therapy
Mass may be present in lower quadrants of abdomen.
Simultaneous involvement of muscles in other parts of body usuallydifferentiates myositis of abdominal wall from intra-abdominal processthat might cause pain in same region.
Referred pain in abdominal diseases
•
Diaphragmatic pleuritis from pneumonia or pulmonary infarction
o
Pain in right upper quadrant or supraclavicular area
•
Referred pain of thoracic origin
o
Often accompanied by splinting of involved hemithorax with respiratory lagand decrease in excursion more marked than seen in intra-abdominal disease
o
Diaphragmatic pleuritis from pneumonia or pulmonary infarction
May cause pain in right upper quadrant or supraclavicular area
Apparent abdominal muscle spasm caused by referred pain
Will diminish during inspiratory phase of respiration
o
Palpation over area of referred pain in abdomen
Does not usually accentuate pain
In many instances, actually seems to relieve it
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